On mental health stigma, and working in a ‘nuthouse’

Quite often, I find myself being quizzed on my job by people I barely know. It’s gratifying that people sometimes find what I do interesting, but, in my experience, it’s often secondary to a problem they have had/someone they know has had. It’s indicative, I think, of the indiscriminate way mental health problems are experienced. There is no protection, really; not money or status or education or any of the things we hope will protect us from the torments of life.

And so it was that I spent a quarter of an hour chatting to some ex-colleagues about my work. Some years ago, I worked in another industry entirely, but I still pop in to the office now and again to say ‘hello’ to my ex-boss. Toward the end of my visit, I got talking to three former colleagues and one person who has joined the firm since I left. ‘What are you doing at the moment?’, one of them asked. ‘Writing m’thesis’, I promptly responded. ‘And what will you be then?’, came the question. ‘A doctor of clinical psychology’, I said. I explained that I was working at a hospital, doing whatever it is that I do and that I am due to qualify in the next few months.  My former colleagues knew that I worked in mental health; the unknown colleague obviously did not. And then came the ‘ooh, how INTERESTING!’ comment, expressed in the worst possible way. ‘What’, she said, ‘is it like working in a nuthouse?’

I am rarely flabbergasted but even I was taken aback. To my shame, when I recovered from the question, I stammered out a deeply ineffectual ‘well it’s hardly a nuthouse’ but I felt like I’d done the people who use mental health services a grave disservice. What I WANTED to say (as I squawked to a friend that evening) was something along the lines of ‘have some bloody respect for people who have experienced untold misery and have demons you can’t even begin to imagine’. Now that’s a bit of a crude statement, because not everyone I see has experienced untold misery and not all have demons (any more than we all have demons, that is). But I was furious at the implication that people who have mental health problems are raving lunatics, locked up for the safety of good upstanding citizens. This is nonsense. People with mental health problems – of whatever persuasion – are not the ‘other’. They’re your parents and friends and bosses and dentists and hairdressers. Notions of Victorian asylums persist, but, when you work in mental health, you get so used to being wrapped up in a woolly world, in which we try to be respectful and aware of vulnerability and the things people have experienced, that it can be rather a shock to encounter a question such as the one I was asked. I don’t think this person had any malign intent; she wasn’t the kind to overtly stigmatise someone with a MH problem, but its not really the overt stigma which is the biggest battle. Yes, it matters that people with MH problems can’t get jobs, for example. But it’s the everyday, insidious stuff which erects the biggest barriers. It’s the casual comments about ‘lazy depressives’ or ‘attention-seeking self-harmers’ or ‘fruitcakes’ , the kind of stuff you hear in the pub, which stops people talking about their own experiences. Interestingly, some of the research indicates that anti-stigma campaigns, which highlight how common MH problems are, actually result in an increase in stigma. Really, it’s the everyday disparagement which needs to be tackled but, if I’m honest, I don’t know you do that. I probably failed, frankly, and I’m still a bit embarrassed by it. If MH professionals can’t pull themselves together long enough to respond effectively to something as relatively minor, perhaps we need to rethink how we tackle something which has a huge impact on the likelihood of people seeking help when they need it. In the UK, we have shockingly high rates of self-harm, suicide and substance use, all of which are often related to unspoken difficulties arising from MH problems. If we could crack the stigma issue, maybe we’d begin to see a shift in these related problems. Sadly, ‘if’ is a big word.

In which I am furious at the Sun for promoting stigma against those with mental health problems and I shout at the Government

I have been meaning to blog for ages. I recently went to a very interesting conference in Copenhagen and spent three days discussing personality disorder, which is one of my primary clinical and research interests. Unfortunately, I’ve been incredibly busy and it’s had to fall to the bottom half of the to-do list. I thought I would make an extra effort today, however, since it is World Mental Health Day.

This seems an apt time to consider some of the issues which persist in mental health. There is the very concept of ‘mental illness’ of course, the battles between the pro- and anti-diagnosis camps, the bickering over effective treatments; all stuff that often goes on in the ivory towers that some of us inhabit. I have always believed that there are two main issues which really affect people with mental health problems and their families: stigma and funding.

i think we’re often quite proud of the way we have come to acknowledge mental health issues in this country, and, to some degree, rightly so. But often success is only lauded because it comes in a sea of perceived failure. So when MPs talk about their mental health problems in Parliament I am pleased, but the very fact that it is such a big deal suggests we still have a long way to go before we truly have an open discussion about the prevalence and impact of mental health problems.

On Monday, the Sun ran this front page:


‘1200 killed by mental patients’. Now the term ‘mental’ went out of use many years ago amongst those us who have some compassion and humanity. News International publications are not, if you will indulge me, known for either their compassion or their humanity. Despite the story admitting that most people who have committed serious violence in the context of a mental illness, the headline will do nothing to eradicate the image of the knife-wielding patient (an image that persists, as we recently saw of the Hallowe’en costumes being sold by Asda and Tesco).

So what are the real figures, the contextual ones? Well, here are a few:

– 1.2 million people in the UK use adult mental health services

– 95% of all murders are committed by people who have NO mental health problem (remember Harold Shipman, who killed hundreds of people?)

– Half of all violent crimes are committed by people under the influence of alcohol

– Around a fifth are committed by those who are under the influence of drugs

– People with severe mental health problems are 10x as likely to be the victims of violence as they are to be the perpetrators

– They are also more likely to harm themselves than anyone else: 90% of people who kill themselves have mental health problems

Given that 15 million people in the UK will have a mental health problem at some point in their lives, and that substances are implicated in the vast majority of all violent crime, this witch-hunt against those who are often very unwell is appalling. But let’s take a look at some more stats:

– Mental health services in the UK have had funding cut by £150m since the Coalition government came to power

– 2000 psychiatric beds have been cut in the last two years. No one, not even the Sun, got angry about that. But I know psychiatrists, good psychiatrists, who openly admit that they are discharging people from hospital when they are still unwell just because of pressure on beds. I have worked on wards where there are three people to a bed and you just hope to God that no one has a relapse whilst they’re on leave, because the chances of finding a bed anywhere in three boroughs is so slim.

– Mental health NHS trusts (which are distinct from physical health, as a general rule) have lost up to 20% of their staff since the cuts came into force. These cuts affect everything from secretarial support to the number of social workers and psychologists available to see those who need such intervention.

– Some of the areas most significantly cut: crisis resolution, early intervention, home treatment teams. In short, the very people who take care of those in crisis; the very people who can intervene if they see that risk is escalating. But they can’t, can they; not when they have caseloads of 60 or 80 people. As someone who works in community mental health services, I tell you this: it is impossible to look after that many people who present a moderate risk to themselves or others and to do it well. As the cuts take hold, services have increased their thresholds and increasingly, only take those deemed to be at high risk. 80 high-risk people cannot be managed by fewer than 2 professionals, and even then they will need intervention from other members of the team.

The fact is this: mental health services are buckling under the strain. Staff are overworked and under-resourced; many are simply burning out. It doesn’t take much intuition to realise that in a job which requires you to deal with people who often have complex needs, this is unsustainable. Newspapers could do a terrific job, if they could be bothered, of putting mental health on the agenda in a positive way. They could get angry about those people who are being denied services they need, not because we don’t want to provide them, but because we simply haven’t the resources to do so. They could make services better for the one in four of us who will have mental health problems – your brother, you best friend, your partner, your mum, your neighbour, your child. They could, if they wanted to. But, like so many others, they simply add fuel to this ghastly fire which means that those with mental illness are further stigmatised, further dehumanised and increasingly seen as the ‘other’.